Laserfiche WebLink
1 1 o <br /> APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTe;G49q��EV, <br /> 1601 E. HAZE T ON AVE.; STOCKTON, CA - <br /> Telephone (209) 466-6781 t <br /> PERMIT EXPIRES 1 .YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> x Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin.County Ordinance No.549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. . I <br /> '� t <br /> Joh Address eAD�' '� � ���^' � ��VLP0Ci�`��OO Lot Size PM <br /> b �j,A raj-] Z Phone Le <br /> mI <br /> Owner's NaeVAddress 1 <br /> Contractor <br /> Address. License No. Phone 'S <br /> TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> '� CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF:WEL-L-�..,.r..PROBLEM-AREA., . <br /> ❑ Industrial ❑ Open Bottom"— ❑:Manteca_ _= Dia. of Well"Excavation Dia of Well Casing" <br /> t �— T of Casing Specifications <br /> ❑ Domes3icl•Private ❑ Gravel Pack ❑ Tracy <br /> Type 9 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ----�pprox. Depth O3 EasternSurface Seal Installed by <br /> t <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction L) Well iameter Sealing yyMaterial (topj50'.. <br /> Depth ` Filler Material-(Below 60'}` <br /> 71 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION❑ DESTRUCTION `(No-septic serr <br /> ystrpermitfed-if public sewer is <br /> available within 200 feet.) I <br /> Installation will serve: Residence torrimercialOther <br /> i _ <br /> Number of living units: f Number� bedrooms� _ a_^. <br /> Character of soil to a depth eof 3 feet: Waterrtable depth ` <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Dtance to nearest: Well Foundation Property Line — <br /> LEACHING LINE ❑ 4. & Length of lines s Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation�P or petty Line - <br /> SEEPAGE PITS ❑ Depth Size + Number*'" <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m st call for requir spectio S. Complete drawing on reverse side. <br /> Signed Title: Date:. <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Area <br /> Pit or Grout Inspection by Date'' Final Inspection byi 4:z� — Date <br /> Additional Comments: °� � r R�' �� 3 ec 0" <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca EIZ0104 ❑ Tracy 835-63 i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> AMOUNT DUE AMOUNT REMITTED GK H RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24 11iEY.i/s ZF—, --ry,] }St <br /> + � <br /> EH 14 28 PP <br /> y. . <br />